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VA Healthcare Purchased from the Community

VA Healthcare Purchased from the Community. Purchased Care Program Integrity Tools. Department of Program Integrity Denver, Colorado May 2013. Topics. Introduction and Overview of the Program Integrity Tools Frequently Asked Questions and rejection Reasons

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VA Healthcare Purchased from the Community

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  1. VA HealthcarePurchased from the Community Purchased Care Program Integrity Tools Department of Program Integrity Denver, Colorado May 2013

  2. Topics • Introduction and Overview of the Program Integrity Tools • Frequently Asked Questions and rejection Reasons • Benefits of the Program Integrity Tools

  3. VA & Source Systems Program Integrity Tools (PIT) Patient Payment Medical Provider Clearinghouse electronic paper PIT High level overview of the flow of claims for the PIT

  4. Claims Scoring Tool Hard Rules SCORING Statistical • Hard Rules • Predefined FWA logical rules • Examples: • LEIE • Duplicate claims Statistical • Fraud Abuse Management System (FAMS) identifies healthcare providers exhibiting suspicious billing patterns • FAMS contains integrated data mining, business logic, and reporting

  5. FAQ - Providers • Frequently Asked Questions by Providers • Will address providers concerns regarding: • Delay in payment • How to bill appropriately • What will be displayed on their PFAR • What to do if a claim is rejected by the PIT • Informational resources available to them regarding the PIT

  6. Rejection Reasons • Match the rejection reason on the VA EOB to the chart on the website.

  7. Benefits of the Program Integrity Tools • Benefits • Safeguards the taxpayer’s investment • Prevents improper or fraudulent payments before they are made • Providers receive education on billing rules • Providers will receive educational letters • Affirms Veterans Affairs’ commitment to excellence to our nation’s Veterans and Beneficiaries, and stakeholders

  8. Program Integrity Website The Department of Program Integrity website will be available Summer 2013. The website will provide information on fraud news, helpful training and development, valuable resources and other necessary tools to help fight against Fraud, Waste and Abuse. Look for additional news and updates advertised on the National Non-VA Care Program Office website under Providers.

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